QC in the ART Laboratory. Ph.D. Lars Johansson, Clinical & Scientific Advisor, Director of Embryology,

Transcription

1 QC in the ART Laboratory Ph.D. Lars Johansson, Clinical & Scientific Advisor, Director of Embryology,

2 AIM Basic Requirements Environment Quality Management Quality of Service Optimization of Outcome

3 Basic Considerations Allocate Rooms & Functions Evaluations vs Treatments? Building Materials, Furniture & Equipment s HVAC (constant temp, particles, VOCs) Gas Support (Pure CO2, mix & N2) Liquid Nitrogen UPS Outlets (Height & Numbers) Transport & Deliveries Easy Access

4 Seasonal Variations in VOCs, TQE & CPR

5 Contaminations Affecting Outcome Components form Outside Ambient Air Laboratory Recirculated Air Tissue Culture Ware Equipment Off-Gassing HVAC Specific Organisms Gas Cylinders - contaminations Personnel Bioburden VOCs MOST HARMFUL!!

6 VOCs vary in their polarity, molecular weight and biochemical structure Require different mechanisms of removal. Must target all biochemical families. Increase the effectiveness. Resonance(removal) and dwell(hold) time.

7 Clinical Pregnancy Rate (%) MEDICULT TVOC Levels (ppb) Analysis of TVOC Loading & CPR within the IVF Laboratory % 54.5% 50.0% 41.6% 64.7% 55.5% 51.6% 41.6% % 37.5% 33.3% % 29.4% TQ1 TQ2 TQ3 TQ4 TQ5 TQ6 TQ7 TQ8 Testing Quarters (TQ) TQ9 TQ10 TQ11 TQ12 The presence of 2.2 ppb VOCs severely compromised clinical outcomes

8 Third Party Independent Testing: 2 CODA Towers + HEPA Final Filters Source Air IVF Laboratory TVOC 1324 ppb 1372 ppb Biologicals: Spores 469 cfu/m cfu/m 3 Particulate 0.3 um 2,318,663 11,642

9 LIFE-Aire VOC Free Ventilation System

10 LIFE-Aire VOC Free Ventilation System

11 Cleanliness: Tightness Factor - Clean Air In/Outlets - Exchange: >20/h - Over-Pressure - Lab: 30 PA - Pre-room: 15 PA - Pharmacy Hatches & Pressurized Door

12 Total Quality Management (TQM) Quality Manager & Quality Manual Covers ALL Aspects Clinic (Financial, Facility, Safety, Patient Care, Staff etc) Treatments Offered Team Work - All Staff Involved & Committed

13 Quality Management QC: Quality Control Provide routine and consistent checks to ensure performance meets predetermined set criteria Identify and address errors and neglected items Documented and archived (paper & wireless) QA: Quality Assurance Verify that quality criteria has been met. Financial, management and service satisfaction. Key Performance Indicators (KPI)

14 24 hours Equipment Surveillance Network (Planer - T, CO2, ph, Humidity, Gas, Particle Count) relay output mains Audible / visual alarming SMS alarming Alarm! Data visualization / management via LAN / web interface

15 QA & International KPI Routine, robust and reliable Laboratory, but not limited to the laboratory Facilitate Auditing Benchmarking against other programs Exchange Ideas / Studies Customer Satisfaction

16 Laboratory KPI Timely Evaluations David Mortimer, ALPHA 2012

17 QA & Factors Factors affecting Outcome & Interpretation Facility & Laboratory Function Patients Demographics & Selection Batch Treatments Expertise / skills (Education, New Staff) Time of evaluation (Suitable Intervals) Products (Hormones, Disposables, Media)

18 Control Charts for Different Parameters (KPI) Plot mean of variables each month (KPI) Average of monthly means expected value Benchmark value Control limits = s.d

19 QA charts

20 But use prospectively Log Book month

21 Quality Improvements (QI) Continuously Performed FOCUS + The Devil is in the Details

22 Education & EQA in Folliculometry, Andrology & Embryology Samples or via Internet SIRT, AAB, FertAid QAPonline Swiss Clinical Embryologists UK NEQAS/ACE EQA

23 Total Quality Management (TQM) Risk Management Adverse Events Complaint Handling Analyse (Root Cause), identify, eliminate & avoid Management System Describe Processes & Procedures Flow Charts Process Mapping Standard Operational Procedures (SOP)

24 Standard Operational Procedures (SOPS) Written Instructions Increase in Standardization Efficiency Transparency Traceability Controlled Activities Reduce Complaints & Failures Facilitates Trouble-Shooting (Auditing)

25 Total Quality Management Manual Organisational Hierarchy Clinics Mission, Vision & Quality Statement Staffing Position within the Organization Job Description Duties, Responsibilities Education & Competency (Written Plan)

26 Pro-Active Actions (SOPs) 1) Cleaning of Premesis and Equipment s 2) Dress Code / Behavior 3) Hand Hygene 4)Preparation of dishes 5)Selection of disposables 6) Waste Handling

27 Media Products & Disposables - QC Specific for Human ART? Certified Quality? CE marked (93/42/EEC) FDA 510k TGA Quality Tested with several tests MEA Sperm survival Endotoxin (LAL)

28 VOC (ppm) MEDICULT VOC Levels: Dishes VOC Levels in Culture Dishes 7,0 6,0 5,0 4,0 3,0 2,0 1,0 0,0 NUNC Petri Dish #50255 (0.7 ppm) NUNC 4-Well Dish # (1.4 ppm)

29 VOC (ppm) MEDICULT VOC Levels: Tubes VOC Levels in Culture Tubes 9,0 8,0 7,0 6,0 5,0 BD FALCON 5ml Tube # (6.8 ppm) 4,0 3,0 2,0 1,0 0,0 NUNC 1.8 ml CryoTube # (1.2 ppm) NUNC 11ml MEA Tube # (0.6 ppm)

30 Eliminate MisIdentification Adverse Effects Double Identification Labelling of dishes Barcodes Stickers ( Laser Etching ( Electronic Witnessing Increase Traceability

31 QC - Standard Semen Analysis Concentration Total number of sperm per ejaculate Motility Deletions within mitochondrial DNA is associated with reduced motility (Ozmen et al., 2007) Morphology THE FORM OF THE SPERM HEAD IS MORE IMPORTANT THAN ITS DIMENSIONS

32 Sperm DNA damage with age

33 DNA Packing, IR & CPR Group Implantation Rate CPR/ET Per ET Per Cycle CMA 3 <44% <CMA 3 <60% CMA 3 >60% Esterhuizen et al, 2000

34 Preparation of Sperm & DNA Fragmentation

35 GM-CSF, Sperm Activation & Time Ejaculated Sperm (Zambrano et al., 2001) Tail Region & Acrosome of Ejaculated Sperm (Naz.,2006)

36 Reduce the Effects of the Paternal Genome on Embryo Development Objective Selection of Competent Sperm Less Fragmentation (D3) Higher Blastocyst Conversion Rate Improved Blastocyst Quality Higher CPR Lower Miscarriage Rate IVF!!!!!

37 N= 537 patients

38 N= 537 patients

39 Egg Collection - QC Anasthesia Stimulation Protocols Dysmorphism short & high doses Temperature Control Tubal Length Needle to test-tube Needle size (gauge): Bleeding & pain Single Lumen Test-Tube Warmer ( ) Speed & Handling Pump Pressure Calibration & Service

40 Evaluation & Scoring (Istanbul Consensus, 2011) Timing of Scoring Important What can/should we score? Oocyte Quality Aggregation or Clustering of SER Imprinting Disorders? High Biochem & Miscarriage Rates (Montag) Large Polar Body (Aneuploidy)

41 Class II Cabinet or LAF 51

42 QC - Handling of COCs Media for rinsing of the COC AA, goodies Control of temp, ph, osmolarity & oxygen Meiotic spindle, embryo development & IR Do not cut COCs Destroy TZP Transfer to Mini-Incubator

43 Incubators Recovery,CO2, ph,o2&temp.

44 DAY 0/2-3 and 2/3-5/6 DAY 0-5/6 Fertilization w/wo GMCSF Cleavage w/wo GMCSF SAGE 1Step Medium 2PN-Blast 5 Days Blastocyst w/wo GMCSF UTM/GMCSF?

45 The ORIGIO Sequential Series = 3 media ORIGIO Sequential Fert For the fertilisation of oocytes. ORIGIO Sequential Cleav For the culture of 2PN embryos to the 2-8 cell-stage (up to day 3). ORIGIO Sequential Blast For the culture of 4-8 cell-stage embryos to the blastocyst stage (from day 2/3). TRANSFER 57

46 Formulation Focus Areas Robustness - Use of pharmacopeia graded products Revised components: - Optimised ionic composition - Optimised energy substrate composition - Optimised amino acid concentrations - Addition of vitamins to Fert and Cleav - New glutamine source (L-alanyl-glutamine) Introduced components: Hyaluronic Acid 58

47 New Sequential Media Control New Seq. Fertilization Rate (%) Cleavage Rate (%) Good quality embryos (%) Blastocyst Rate (Day 5, %) Good quality blastocysts (%) CPR per patient (%) 48 62

48 Sage Single-Step Medium Same Results as the Competition Culture Techniques - No need for changing media - Culture from 2PN Blastocyst (Day 5) 60

49 Precipitates Precipitates of Calcium Carbonate occurs when Vials/flasks are frequently opened which increases the ph Use small vials If you store aliquots of media under 5% CO2 at low temperature (2-8C). Do not aliquot!!!

50 Recommended ph of Commercial Media Swain RBM Online :6-16

51 Courtesy of Kathy Miller Optimum ph for Cleavage Medium N= 96, 431 embryos

52 Courtesy of Kathy Miller Optimum ph for Blastocyst Medium N= 39, 567 embryos

53 Reducing the negative effects on/off oil Mineral oil is a mixture of various hydrocarbons. Unsaturated hydrocarbons are more susceptible to peroxidation (POVs), which is embryo-toxic. Light & UV light increase the peroxidation. Store in dark. Heat and prolonged storage increases peroxidation. Store at low temperatures (2-8 C). Companies pre-wash oil with water or medium

54 Low Oxygen (5-6%) = Low ROS Reduce chromosomal mosaicism: - Blastomeres - Sex Chromosomes Cleavage Pattern Blastocysts Higher Cell Numbers Lower Apoptosis On time development Bean et al., 2002, Dunn et al., 2012

55 Other considerations QC Micromanipulation MEDICULT Which ICSI? Heating, Anti-Vibration, Location.

56 QC Equipment s Particles, Temp, CO2, O2, ph, VOCs

57 NON-CUMULASE All are testicular enzymes from slaughterhouse animals ICSI-CUMULASE Recombinant human enzyme (rhuph20) Purity not ensured many unknown substances Contents of typical products Extremely high purity > 99% pure Bovine (Type IV-S) Ovine (Hyase) Human (Cumulase)?? Cumulase (rhuph20)

58 Regulation of phi during Oogenesis, Embryogenesis & Denudation

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60 Spindle Dynamics and ICSI Spindle Bridge MI > MII min MII min Montag 2012 ALPHA

61 Culture Techniques Open vs Micro-drops? Small drops (20 40 ul) Airflow & High temperature Higher osmolarity Bad Embryo Development (Swain et al., 2012) Single vs Group Culture Sequential Evaluation Paracrine & autocrine & ph? Day 1-3, Better Outcome (Ebner et al., 2010) After Compaction, single (Lane, FSA 2008)

62 Direct cleavage (DC) from 1 to 3 Cleavage from 1-blastomere to 3-blastomeres in less than 5 hrs Rubio et al 2012, Fertil & Steril

63 Blastomere Size and Genetic Health photomicrographs courtesy of Dr S Pickering

64 De-Selection Cleavage Patterns t2 t3 t4 t5 cc1 cc2 cc3 t2 t3 < 5 hrs t4 t5 t6 cc1 cc2 cc3

65 Aneuploidy / Morphokinetics: PGD

66 Factors affecting MEDICULT Age morphokinetics Stimulation ICSI Etiology Media Handling Embryo Development t2 t3 t4 t5 t8 cc1 cc2 cc3 s2 s3 Maturity Oxygen Temperature ph Biopsy Aneuploidy Viability?

67 Day 3 vs Day 5 Biopsy Age Group D3 IR D5 IR D3 AR D5AR Harton et al., ASRM 2011

68 ID Monitoring Risk Reduction Electronic witnessing

69 Lasers: - AHA on Day 3/4/5 Octax

70 Assisted Hatching with Laser Hands not removed from manipulators. Laser fired with foot pedal Easier to target cell junctions Allows aspiration during ablation Movable and no calibration

71 Uterine Transfer Medium (UTM) / GMCSF Clinical pregnancy Hyaluronan Conventional Implantation Effect of hyaluronan-enriched transfer medium Urman et al 2008 beneficial effect was more prominent in women >35 years of age, and in women who had poor-quality embryos

72 Vitrification - QC Toxicity of components reduced by Speed of handling Short exposure to final vitrification solution Rapid warming Survival Rates & Developmental Competency Selection of high quality gametes & embryos Whole vitrification process optimized

73 FET better than fresh? Kato et al., 2012

74 Thank You! Questions?